HT940723Q0001 Attachment 04 - Quote Form.pdf

QUOTE FORM

10 MDG AMBULANCE SERVICES

VENDOR INFORMATION:

Vendor Name: ______________________________________________________

CAGE: ____________________________________________________________

Unique Entity Identifier (UEI): _________________________________________ Address: ___________________________________________________________

Name of Representative Authorized to Obligate the Government: ______________ Phone Number: _____________________________________________________ Email Address: _____________________________________________________

EXPERIENCE:

Using the following three tables, provide details for no more than three recent and relevant contracts that demonstrate your company’s ability to fulfill the requirements of this PWS. To be considered recent, contracts must have been performed, in part or in full, within three years from the closing date of the solicitation. If you choose to submit fewer than three experience summaries, leave unused tables blank.

Did any of your experiences require your company to perform 24-hour emergency response operations?

Yes. Provide experience number: ____________________________________________ No

Did any of your experiences require your company to perform services for special events comparable to an NCAA football game?

Yes. Provide experience number and explain: __________________________________ No

Did any of your experiences require you to provide a dedicated independent medical director like that required by 6 CCR 1015-3?

Yes. Provide experience number: __________________________________ No

Experience Summary #1

Contractor Name, CAGE Code, and Unique Entity ID:

Relationship to Contract Holder:

(specific relationship such as prime contract holder, subcontractor, teaming partner, etc.)

Contract Number:

(For Indefinite Delivery type contracts, GSA contracts, and Blanket Purchase Agreements, include Task Order Numbers)

Contract Value:

(including all options)

Funded Value:

(this value reflects total funds obligated to the contract)

Period of Performance:

(including option periods)

Contracting Officer’s name, e-mail address, and telephone number:

Technical Representative or Contracting Officers Representative’s name, e-mail address, and telephone number:

General description of services required under the contract:

Experience Summary #2

Experience Summary #3

ADDITIONAL QUESTIONS:

Anticipated teaming arrangements for this requirement:

Prime Only Subcontractor(s) Joint Venture Other

If other than “Prime Only,” explain the anticipated arrangement, to include what portions of the requirement will be subcontracted or performed by other than the prime:

Ambulance Vehicles

Does your company own at least three ambulances that will be available to be dedicated to performance of this contract?

Yes No

If no, explain anticipated method of obtaining and dedicating ambulance vehicles to meet the requirements of the PWS:

Briefly detail your anticipated plan to recruit/retain personnel, including a medical director, and maintain applicable licenses, certifications, accreditation, and/or credentials. Also detail how your company will obtain any necessary certifications/registrations required to perform emergency medical services in the Colorado Springs area :

ADDITIONAL VENDOR INFORMATION:

You may use this page to further elaborate on any preceding question or to provide any additional information you wish the government to consider when evaluating your quote. Use of this page is not expected or required.